Provider Update Newsletter
November 2001, Vol 109
All Providers
HIPAA Happenings
DHS Accomplishments 2001
Missed Appointments
Annual Provider Survey
RIteShare
CEDARR Family Centers
Connect CARRE Program
Adjustments and Recoupments
Pharmacy Providers
Medicare Beneficiaries
RIteShare and TPL Billing
Personal Care Providers
EPSDT Personal Care Codes
Physicans and Home Care Providers
Flu and Pneumonia Vaccine
Lead Center Providers
New Standards
HIPAA Happenings
It is now less than one year to HIPAA Transaction and Code Set compliance - do you know
where your impacts are? Click on the following links to view the HIPAA Implementation Guides and the free Medicaid HIPAA Compliant Concept Model, a HIPAA
Assessment Tool.
If you maintain your own claim billing systems, has someone checked to make sure you will
be able to process all the new claims Transaction Sets due to the loss of UB-92’s,
HCFA-1500’s, waiver and TAD electronic claim formats? Do you know there is a national published schedule for the rollout and testing of
these new Transactions and Code Sets?
If you use other vendor software or a clearinghouse to process your claims, have you asked
your vendor if they expect to be HIPAA-compliant on October 16, 2002? Do you know what
kind of changes or training you’ll need to complete the new Transaction Set billings?
It is likely there will be changes required for paper claim forms too. Is anyone in
your office monitoring the CMS (formerly HCFA) Web
site for this information?
Are you aware that Medicaid and other payers will no longer be permitted to use
“Local Codes”? DHS/Medicaid is working hard on the Local Code issue and we hope
to have “new” standard codes out to Providers during the summer of 2002.
However, we suggest you continue to monitor HIPAA Happenings and our web site for these
changes too.
While Privacy Final Rule compliance isn’t due until April 14, 2003, has your officer
appointed a Privacy Officer yet? Have you begun development of ongoing Privacy Training
programs that will meet HIPAA requirements? Have you developed formal procedures
concerning the access to, and release of, Protected Health Information (PHI)? Have you
reviewed your patient consent forms and information tracking procedures to make sure they
comply with HIPAA Rules? Please visit CMS’ site
for Privacy Guidance and FAQ’s. The American
Medical Association also has great HIPAA information.
If you need further information regarding HIPAA, or a “HIPAA 101” session at
your office, please call (401) 462-6392 or contact the Web Master.
Please don't forget---- ITEC conference at the Providence Convention Center on November 13
and 14, 2001. Will be HIPAA heavy!
DHS Accomplishments 2001
During 2001, the RI Dept of Human Services introduced new programs and enhanced
existing services to further meet the Department's Vision: "...to offer a full
continuum of services for families, adults, children, the elderly, those with disabilities
and veterans". Many of these new programs utilize case managers to provide
coordinated services for individuals with special needs and improve health outcomes.
· CEDARR Family Centers began providing initial family assessments,
family care plans, specialty evaluations, family coordination assistance and crisis
intervention for children with special needs and their families.
· RIte Share, a health insurance premium assistance program was
implemented. This program will help Medicaid eligible employed individuals maintain or
obtain employer-sponsored health insurance for their family. RIMAP will pay all or part of
the employee share of their health of their premium, co-payments and provide some
additional benefits.
· Rhode Island was the first of four states to implement the Breast and
Cervical Cancer program working with the Department of Health. This program provides the
full scope of Medicaid benefits for women between the ages of 40-64 who meet the criteria.
Two page applications speed the process for approval.
· Connect CARRE, an initiative by DHS in a partnership with
Neighborhood Health, is a care management and wellness program for individuals with
chronic illness living in the community. The program provides complete care management to
improve overall health.
· The Department of Human Services converted 2,242 foster children from
Medical Assistance coverage to RIteCare coverage.
· The Department completed a survey of disabled adults.
Missed Appointments
It is a violation of Rhode Island Medicaid Policy for Providers to directly bill
Medicaid Recipients for broken and/or missed appointments. Medicaid pays only for services
rendered. Missed or broken appointments result in no services being rendered to these
recipients. Please review your financial sheets for Medicaid Recipients and reimburse any
recipients who may have paid you for these “non-appointments”.
Annual Provider Survey
EDS, in conjunction with the Rhode Island Department of Human Services, is conducting
the seventh annual Provider Survey. Our commitment is to continually improve our services
to you. This survey assists us in monitoring our progress toward achieving outstanding
service to the provider community. The last six surveys indicated satisfaction with our
services, and gave us feedback to prioritize your issues. EDS encourages you to reply and
identify your facility to help us provide educational training to you. Your reply is kept
confidential.
The survey is provided to hospitals, nursing homes and to 10% of all other active provider
communities. The surveys were mailed in October. Once the feedback from the survey is
compiled, we will publish the results in an upcoming provider update.
Remember your feedback is crucial to the continued success of improving services to our
provider community.
RIteShare
When providing treatment to a RIteShare member, providers should deliver care based on
commercial benefit limits with individual carriers then bill that carrier accordingly. For
member co-payments, providers should bill RIMAP through EDS using the following:
Physicians and Other Medical Professionals:
State code X0700 for reimbursement of co-payments.
DME only:
State code X0701 to bill for co-payments.
Hospitals/Home Health:
Utilize bill type 994 for reimbursement.
Pharmacies:
Bill on paper with the mock NDC 99999-1111-11.
RIteShare members are given two health insurance identification cards
one from their employer-based coverage, one from the Medical Assistance Program.
RIteShare members can be identified through the REVS line by calling the Customer Service
Help Desk at 401-784-8100.
CEDARR Family Centers
CEDARR Family Centers are designed to provide services to children with special health
care needs and their families.
What does CEDARR stand for?
C - Comprehensive
E - Evaluation
D - Diagnosis
A - Assessment
R - Referral
R - Re-evaluation
What Services are offered at CEDARR Family Centers?
All CEDARR Family Centers offer the following services:
· Initial Family Assessment
· Family Care Plan Development
· Specialty Clinical Evaluation
· Family Care Coordination Assistance
· Crisis Intervention Services
CEDARR Family Center services are available statewide
For more information about CEDARR Family Centers contact:
About Families - CEDARR Family Center
32 Branch Ave.
Providence, RI 02904
(401) 331-2700
Family Solutions - CEDARR Family Center
134 Thurbers Ave., Suite 102
Providence, RI 02905
(401) 461-4351 or (800) 640-7283
More CEDARR Family Centers will be opening soon!
Connect CARRE Program
Connect CARRE - Coordinated Assessment Referral Re-Assessment Evaluation is a complete
care management and wellness program developed by the Department of Human Services and
Neighborhood Health Plan of RI. The program is for individuals age 22 or older with
disabilities and certain chronic diseases living in the community.
Connect CARRE includes a Nurse Care Manager who will work with the member’s doctor,
pharmacist and other providers. The case manager will assist members and their families
with managing illness and coordinating services to improve the overall health of its
members.
For more information please call Ellen Mauro, RN Program Manager at DHS (401) 462-6311.
Adjustments and Recoupments
Single and Multiple Adjustment Request Forms :
The Single Adjustment Request Form and Multiple Adjustment Request Form are used to
request adjustments of paid or partially paid claims. The forms cannot be used to resubmit
a denied claim, inquire about policies or procedures, or check a claim's status. Inquiries
can be directed to the EDS Customer Service Help Desk (CSHD) at (401) 784-8100 or
1-800-964-6211. Copies of the forms can be downloaded from the Provider
Forms Page.
Information Required:
Each claim adjustment request will be reviewed based on the information entered on the
form. This information should be as accurate as possible. Copy the Internal Control Number
(ICN) of the claim in question, as well as the recipient's name and Medical Assistance ID
number directly from the Remittance Advice (RA). The reason for the adjustment should be
as specific as possible.
Attachments:
The Remittance Advice (Settlement) must be attached to the Adjustment Request Form for
processing. If appropriate, a copy of an Explanation of Benefits (EOB) or payment voucher
from a third party payer should also be attached.
Timely Filing:
Adjustments/recoups are subject to this legislation. The time frame is one year from the
paid date on the Remittance Advice (Settlement). Should you have further inquiries please
call the Customer Service Help Desk at (401) 784-8100 for further assistance.
Medicare Beneficiaries
Every quarter we receive an overwhelming amount of paper claims to be processed because
a recipient has exhausted their Supplemental Medicare Drug Benefits. Once a recipient has
exhausted their Medicare Supplemental Drug Benefits for the quarter, pharmacies can bill
RI Medicaid as the primary insurer. This can only be done after the pharmacy calls the
Third Party Liability (TPL) department at EDS. By following the steps below you can reduce
the number of paper claims filed each quarter.
· Call the EDS TPL department at (401) 784-3877 when you receive a
message from the primary insurance indicating the recipient has exceeded plan limitations
or exhausted their drug benefit.
· You will need the recipient’s MID and other insurer information
(membership and group numbers).
· The TPL department will verify that the recipient has exhausted their
drug benefits for the quarter with the primary insurance. Once coverage is verified, the
TPL department will update the MMIS to reflect this information.
· The next day you can file a claim for prescriptions with RI Medicaid
as the primary insurance. Covered drugs will be paid as per policy.
This procedure needs to be repeated each quarter, as there is no current procedure to
track the prescription drug expenditures of each recipient who has Medicare supplemental
insurance.
RIteShare and TPL Billing
This is a reminder to all Pharmacy providers that as of August 28, 2001 EDS has been
accepting secondary billing and RIteShare billing on line via POS and any other electronic
means, which follows the NCPDP 3C/3.2 format. Please refer to the August 3, 2001
correspondence for specifics. Should you require a copy of the correspondence or have any
further questions regarding either program, please feel free to contact Ingelcia G. S. Jiran, Pharmacy
Coordinator, at (401) 784-3818.
EPSDT Personal Care Codes
The following codes no longer require prior authorization and have a maximum of 8
units:
X0087-EPSDT nursing services- personal care - 1 hour
X0089-EPSDT nursing services- personal care - 1/2 hour
Flu and Pneumonia Vaccine
Flu and Pneumonia Season Is Here!
The Department of Human Services (DHS) is engaged in an Outreach effort to notify
high-risk recipients of the benefit of flu and pneumonia immunization. DHS will reimburse
for the influenza and pneumonia vaccines for “Fee for Service” Medicaid
recipients (21 years or older).
The current codes are:
| Influenza Vaccine
90658 $ 3.49 |
| Administration of Influenza Vaccine G0008
$ 4.71 |
| |
| Pneumonia Vaccine
90732 $11.44 |
| Administration of Pneumonia Vaccine G0009
$ 4.71 |
A. When the vaccine is administered during an office visit, the serum
can be billed in addition to the office visit. The fee for administering the vaccine,
however, is included in the office visit charge and cannot be billed separately.
B. When the recipient receives the vaccine without an office visit, such
as at a “Flu and Pneumonia Immunization Clinic”, both the vaccine and the
administration fees can be billed. Claims must be individualized by recipient and include
the proper place of service. If the place of service is not referenced in your Provider
Manual (i.e. housing authority), please use 99.
C. If a recipient is receiving home care services, a skilled nursing
visit may be made to administer the vaccine(s). The serum can be billed for in addition to
the skilled nursing visit. The fee for the administration of the vaccine is included in
the skilled nursing visit and cannot be billed separately.
New Standards
Lead poisoning has been recognized as one of Rhode Island’s most critical health
problems affecting young children. Several hundred children are lead poisoned each year in
the State. Lead poisoning has serious implications for these children’s present and
future health status, with known serious effects on future growth and development.
A recent published study indicates that over 30% of RIteCare enrolled two year-olds have
lead levels of over 10 ug/dl. Concerned by these findings, DHS has decided to revise its
Lead Center Standards so that more children can receive current Lead Center services which
are geared toward reducing exposure to lead. DHS will:
· Provide all Medicaid and RIteCare enrolled children with elevated
blood lead levels equal to or greater than 15 ug/dl Lead Center services
· Expand the service area to include Warwick and Cranston
· Remove prior authorization requirements for intensive case management
services by the Lead Center
The following codes no longer require prior authorization:
X1682-Case Management-Intensive-monthly rate-less than 4 months
X1684-Case Management-Maintenance-monthly rate billed after initial 6 months
The above revisions to the Lead Center standards are effective immediately. DHS will
release new lead center standards by November 1, 2001.
There is a new link on our site for Lead Resources.
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